HSS Change of Ownership Information: Hospital
Providers must complete this document when they have a change in their ownership structure. This document would be used for both a change of ownership (CHOW) as defined by state and/or federal regulations, or a change of ownership information (CHOI) that does not meet the state and/or federal regulations CHOW definition.
For Health Standards to make a CHOW/CHOI determination, all providers must submit the following documents:
- Letter of Intent (including d/b/a (doing business as) and entity name of the previous and the new owner, the effective date of change of ownership, address and phone number).
- A diagram showing the ownership structure “before” and “after” the change
- Copy of the executed legal transaction documents (Bill of Sale, lease, etc.)
- CHOW/CHOI License Application
- Change of Ownership Application
- 855A/B approval letter for the following Medicare Certified providers: Home Health, hospice, hospitals, RHCs, ASCs, ESRDs, portable x-ray, community mental health, CORF, Nursing Facilities, and OPT.
Note: If this action is a CHOI, the documents above are the only documents you need to submit, however the Department may, at its discretion, request additional documentation in support of the CHOI. If so, you will be contacted for any of said additional documents. There is no fee for a CHOI.
If this action is a CHOW, the following are also needed:
- Does your facility have a CLIA Certificate? If yes, you may also be required to complete a CHOW for CLIA.
Note: The fee for a CHOW is usually the same as a license renewal unless the facility is making additional changes. For providers completing an acquisition/merger, please contact the program desk for assistance.
Additional Documents Required:
- *License Application Emergency Preparedness Addendum form (Medicare Certified Hospital)
- *Form CMS-1561 Health Insurance Benefit Agreement (Medicare Certified Hospital)
- *Electronic verification from the Office of Civil Rights (OCR) of successful submission. (Medicare Certified ?Hospital) Click here for the form
- OSFM inspection
- OPH inspection
- Worksheet for Hospital Beds & Rooms
- Plan Review
- Plan Review Attestation
- Office of Civil Rights
For all other Change of Ownership Information, please contact the HSS Ownership Group